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Physician Trial Form

613034700
C Scope Kit 10 Pack
613034701
C Scope Kit 2 Pack
613034702
C Scope Kit 5 Pack
Reorder No.
Description
Lot Number
Quantity
To be signed by doctor
A trial procedure is being performed with a demo C Scope tablet, and demo hardware does not automatically prevent scope reuse. I acknowledge that the C Scope kit is single-use and will be discarded once the procedure is complete.
To be signed by sales rep
I acknowledge that the C Scope handpiece has been reprocessed with Caviwipes according to the user manual and all patient information gathered during the trial procedure has been deleted from the C Scope tablet.

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ZSC-200-08-08-20 Rev. 02